A basic premise of obstetric practice is to optimize pregnancy outcomes through preventive and ameliorative
From Saint Louis University, St. Louis, Missouri; and Tulane University, New
Orleans, Louisiana.
This research was funded by the National Institute of Mental Health (R01/
MH57736-03), SLU2000 Research Initiative, and Saint Louis University
Beaumont Award.

treatment. One area of clinical practice gaining increasing attention is the mental health of pregnant women and
its effect on birth outcomes. Community prevalence
studies estimate that 20 –30% of all women experience at
least one psychiatric disorder in a given year. Women of
childbearing age have even higher reported rates.1–3
One psychiatric disorder affecting a disproportionate
number of women of childbearing age is posttraumatic
stress disorder, with lifetime rates ranging from 10.4%
to 13.8%.4 –7
People diagnosed with posttraumatic stress disorder
usually have experienced or witnessed life-threatening traumatic events that elicit feelings of horror, terror, and fear.8
For women, the precipitating events most often are rape,
childhood physical abuse, physical assault, or being threatened with a weapon.4,5,7 A large proportion of women
experience trauma before the age of 25 years.6 Common
symptoms of posttraumatic stress disorder include intrusive recollections of the traumatic stressor, avoidant/
numbing behaviors, and hyper-arousal symptoms.8
Little research has focused on posttraumatic stress
disorder in pregnancy to estimate either its prevalence or
the likelihood of treatment for the disorder. Consequently, this study aims to estimate the prevalence of
posttraumatic stress disorder in economically disadvantaged pregnant women, describe the proportion of
women receiving treatment, and identify the associated
risk factors that can facilitate screening for the disorder in
clinical practice.
MATERIALS AND METHODS
Using a prospective cohort design, we recruited 744
pregnant Medicaid-eligible women at Women, Infants
and Children Supplemental Nutrition Program sites in
the city of St. Louis and in 5 rural counties in southeastern Missouri. Both areas have high levels of poverty and
rates of infant mortality and low birth weight infants that
exceeded national averages at that time. The sample was
limited to black and white women, because they make up
the vast majority of the population in both geographic

0029-7844/04/$30.00
doi:10.1097/01.AOG.0000119222.40241.fb

Only 160 (21.
* General Equivalency Diploma is coded as high school graduate.0
Values are n (%) unless otherwise specified. had
experienced at least one previous live birth.8%) were in their second trimester.0%)
refused to participate. and 18 other common psychiatric disorders were
Cook et al
Posttraumatic Stress Disorder in Pregnancy
711
.locations.
Louis and 1 rural site refused or were unable to participate in the study. 2 sites in the city of St. NO.0)
305 (41. The Diagnostic
Interview Schedule. assesses the presence of current and lifetime
psychiatric diagnoses based on symptom.8)
356 (47.5%) were black. and 316 (42.
Posttraumatic stress disorder. Despite their relatively
young age.8)
59 (7. Eligible women were enrolled at each site until their
numbers were proportional by race for women seen at
the respective site.3 ⫾ 5.9)
8 (1. 428 (57. 4.0
4. in addition to race.5%) first receiving
care in their second trimester. This was determined by having 12 or more
errors on the dementia section of the Diagnostic Interview Schedule. severity. Two of 5 mothers (41.5)
311 (41.7%)
women received prenatal care for the first time during
their last trimester.8%) or 311 partic-
VOL.5 ⫾ 4. Mothers as
young as 13 years old were included. and
duration criteria in the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders-IV. Maternal age ranged
from 13 to 43 years. 59. having (or being eligible for) Medicaid coverage of health
services. 41.
ipants had not finished high school.5)
21 (2.
geographic location. research assistants obtained informed consent from eligible pregnant women who
sought services at their local Women. However. Louis (305
of 744. and 11 (1. Nine of 10
women (672 of 744) had their initial prenatal care visit in
their first trimester.
Of the total 878 women approached.6%) were unavailable for scheduled
interviews. Past interpretations
of Missouri statutes allow pregnant minors to consent to
medical care and participate in research without parental
consent.5%) were
white (Table 1). 192 of 744 (25. Another 303
(40. or 161 of the 744 subjects.0%).8
Following approval of the study protocol by the Institutional Review Board.5%) of the 744 women
were married.8%) delivered a previous pregnancy more than 3
weeks early. Only 5 of 744 (0. and the remaining 279 (37.8)
39 (5.1)
10 (1.9)
22.3)
523 (70. Infants and Children
Supplemental Nutrition Program enrollment at any
point in their pregnancy. Only one subject was ineligible because
of cognitive impairment.
State-level data on the number of pregnant women seen
at the identified sites in the previous year overestimated
eligible subjects for the study period.8%) reported having had at
least one serious medical problem in their lifetime. with a mean of 22.5%) were in their last trimester. APRIL 2004
Table 1. Replacement sites in the same geographical areas were selected based on their willingness
to participate. Eighty-four
(18. Our original plan was
to sample participants from all the rural sites and representative urban sites. thereby precluding
the random sampling of black and white subjects at each
site.
Inclusion criteria for subjects.5
3.0%) initially refused to enroll.
One of 5.0%) than in the city of St.8)
43 (5.1)
439 (59.8%) did not appear for their interviews. and Women. Infants and Children Supplemental Nutrition Program sites between
February 2000 and August 2001.0)
508 (68. 132 (15. Exclusion criteria included cognitive impairment that interfered with understanding of the interview
questions. Nearly 60%. More women resided in the rural Missouri (439 of 744. with another 56 (7. and 171 of 744 (23.
†
Full-time work is 35 hours or more per week.3)
160 (21. Sociodemographic Characteristics of Sample (n ⫽
744)
Characteristic
Race
Black
White
Education*
⬍ High school
High school graduate
Vocational or some college
Bachelor’s degree
Graduate degree
Marital status
Never married
Married
Separated
Divorced
Widowed
Residence
Rural
Urban
History of serious illness
None
One
Two
Age (y)
Mean ⫾ standard deviation
Median
Full-time work in last year (mo)†
Mean ⫾ standard deviation
Median
n (%)
428 (57.0%) enrollees
were under 19 years of age. 14 (1. a well known standardized diagnostic
interview. included being pregnant. 103.5)
316 (42.3)
1 (0. and 25 (2. Ninety-three (11. Of the 744 women who did participate in the
study.3 ⫾ 5.2 (standard
deviation [SD]) years. and being able to speak English. were interviewed
during their first trimester of pregnancy.5%) received no prenatal
care at all.2
21. All eligible women were then enrolled at
each site in the order in which they were identified. Trained research assistants administered a
2-hour in-person interview using the Diagnostic Interview
Schedule9 and other study instruments.3)
192 (25. treatment for the disorder. or 428 of 744 of the women.

1%) reported
difficulties with family. 89. Cary. Fourth.2%). They were somewhat less
likely to report a sense of having a foreshortened future
(31 of 57.9%) reported 1
or more comorbid psychiatric disorders. 61. environmental. 91. Second. onset of
symptoms. 35. we
calculated the prevalence of current posttraumatic stress
disorder and assessed treatment for this disorder. and being in a
serious accident (18 of 57. age of exposure. Forty-one women (71. friends. we calculated adjusted odds ratios (ORs) with 95% confidence
intervals (CIs) to identify those risk factors that could be
used as screening criteria to identify pregnant women
with posttraumatic stress disorder in clinical practice. 12.6%).
irritability or outbursts of anger (51 of 57. attitude about pregnancy.9% (7 of 744) reported symptoms of posttraumatic stress disorder but did not meet the criteria of
Diagnostic and Statistical Manual of Mental Disorders-IV for a
current diagnosis. 96. 7.
and pregnancy-related factors and posttraumatic stress
disorder.1%) had 2.3 ⫾ 0. being mugged
or robbed (26 of 57.4 (SD) traumatic events over their
lifetime. First.8 [SD]).
we fitted logistic regression models to the data to determine the association between medical. experiencing a natural
disaster (22 of 57. The posttraumatic stress
disorder module of the Diagnostic Interview Schedule
begins with a list of 17 traumatic events. 50.4%) or an inability to recall important
aspects of the trauma (7 of 57.8%)
of the 57 women experienced the traumatic event that
precipitated posttraumatic stress disorder before they
were 15 years old.
712
Cook et al
Posttraumatic Stress Disorder in Pregnancy
RESULTS
Of the 744 women in this study. 8.9%). 38. Fourteen
(24.6%) had 1 comorbid psychiatric diagnosis. 31.
OBSTETRICS & GYNECOLOGY
. psychological
distress when exposed to cues resembling the trauma (55
of 57.6%). and another 16 (26. We used a 5-step analytic strategy. 101 (13. seeing someone being seriously injured or killed. 12
(21. We tested our model for goodness of fit using
the Hosmer and Lemeshow statistic.
NC).
The most commonly reported symptoms of posttraumatic stress disorder were intrusive distressing recollections of the trauma (57 of 57. we created
descriptive statistics and summary profiles.5%). 100. pregnancy-related morbidity. In this study. places. In comparison with other current
psychiatric disorders examined. difficulty concentrating (52 of 57. Another 0.8%) and nicotine dependence (63 of 744. following major
depressive episode (80 of 744. as well as symptom counts.3%). living conditions. and stressors. based on a scale ranging from 0
(none) to 4 (severe). One in 13 women (57 of 744.
Data entry with verification and statistical analyses
were conducted using SAS-PC 8 (SAS Institute.9 This lay-administered standardized interview assesses diagnostic criteria in Diagnostic and
Statistical Manual of Mental Disorders-IV. or people associated with
the trauma (51 of 57. being sexually assaulted by a nonrelative (29 of 57. and treatment.
Posttraumatic stress disorder is precipitated by exposure to one or more traumatic events. Twenty-one (36.
Items adapted from the Pregnancy Risk Assessment
Monitoring System10 provided information on pregnancy history and environmental stressors.6%). or being in a natural disaster. On average. 89. Developed
by the Centers for Disease Control. degree of
disruption in work or social relationships. Twenty-eight of the 57 women with
current posttraumatic stress disorder (49. posttraumatic stress disorder during pregnancy was based on
symptoms occurring in the 12 months before and including the pregnancy interview. Third.5%).5%).
Measurement of sociodemographic characteristics
was based on items in the Diagnostic Interview Schedule.1%). and
avoidance of activities.
84. seeing someone killed or
seriously injured (22 of 57.6%). The most common events included the unexpected death of a close friend or relative (48 of 57. being sexually assaulted by a relative (20 of 57. pregnancy. 10. Finally. Treatment for posttraumatic stress disorder focused on whether or not subjects
talked to a physician or other health professional about
posttraumatic stress disorder–related behaviors or feelings in the past year.
and environmental characteristics between women with
and those without posttraumatic stress disorder.2%) had 3 or more.
we evaluated risk factors for posttraumatic stress disorder using ␹2 tests and Student t tests to identify any
significant differences in sociodemographic. experiencing combat conditions.6%). the 57
women with current posttraumatic stress disorder had a
mean of 4. onset and recency of symptoms. having something terrible happen to a close
friend or relative (35 of 57.measured by using the fourth version of the Diagnostic
Interview Schedule.6%) had a
diagnosis of posttraumatic stress disorder at some point
in their lives. 54. 38.4%).7%) had a
current diagnosis of posttraumatic stress disorder.2%).9 ⫾ 2. and treatment
in the previous 12 months.
Pregnant women with posttraumatic stress disorder
reported moderate impairment in their daily functioning
(mean 2. including being
attacked or raped. this instrument
assesses maternal health indicators related to prenatal
care. posttraumatic stress disorder was the third most common.0%).
Subjects identify the worst event that ever happened to
them and then respond to questions about posttraumatic
stress disorder symptoms. remission. and/or work during the
same time period. 45. being
threatened with a weapon.

1
24
13
2
32
42. generalized anxiety disorder. women who received services had significantly
more comorbid psychiatric disorders than those who did
VOL.8. 35. They also
were significantly more likely to report separation from
their mother as a child for more than 6 months and to
have experienced multiple traumas in their lives.3
9.5
3.9
0.
The next analyses focused on identifying those characteristics associated with risk for posttraumatic stress
disorder. generalized anxiety disorder
(11 of 57. women with posttraumatic stress disorder
in this study had 1.05). P ⬍ .2%). Current Comorbid Psychiatric Disorders in Pregnant Women With Posttraumatic Stress Disorder (n ⫽ 57)
Prevalence
Comorbid psychiatric disorder
Number*
%
95% Confidence limit
11
10
3
2
1
20
19.3
59.8%). APRIL 2004
not receive services (mean 2.9.0
13.26.8
1. The remaining subjects
(35 of 57. 9. 35.
A statistical model was developed to identify risk
factors that would facilitate the clinical identification of
pregnant women with posttraumatic stress disorder.2
10
6
2
1
1
1
13
17.8. 8 did receive treatment for another psychiatric
diagnosis.1
11. women with the disorder were significantly more
likely to have had one or more serious medical illnesses
in their lifetime and to have met the diagnostic criteria for
major depressive episode.3%).5
10. 61. and nicotine dependence. 9. Of individual comorbid diagnoses.8
71.5 ⫾ 1. followed by anxiety and substance-related
disorders (Table 2). 17. despite
its known association with posttraumatic stress disorder.5
56.1. respectively. 11. 26.0 [SD] and 1.7 (SD) comorbid diagnoses.
Only 7 of the 57 women with current posttraumatic
stress disorder (12.8. There were no statistically significant differences in sociodemographic characteristics between
women who did and did not receive treatment.0. environmental.8
1.1
30.0. 11.6 ⫾ 2.8
3.3%) received treatment in the previous year for this disorder.5%). 31. However.5
[SD]. 9. 29.2. 48.
and medical risk factors (Table 3). 55.0.
Pregnant women with posttraumatic stress disorder experienced significantly higher levels of life event stress
and physical abuse in the previous 12 to 15 months than
women without posttraumatic stress disorder.8.1
1.3
0.8
35.5
1. t ⫽ 2.0.
On average.3
3. 42. Relatively few
women reported alcohol abuse or dependence.3
17.9
43. 9.5
1. risk factors were identified that
significantly differentiated women with and without the
Cook et al
Posttraumatic Stress Disorder in Pregnancy
713
. 68.3.4%) neither wanted nor received treatment
for this disorder.4
1.9
Anxiety disorder
Generalized anxiety disorder
Social phobia
Obsessive-compulsive disorder
Specific phobia
Panic disorder
Any anxiety disorder
Mood disorder
Major depressive episode
Manic episode
Hypomanic episode
Any mood disorder
Substance-related disorder
Nicotine dependence
Marijuana abuse and/or dependence
Alcohol abuse and/or dependence
Amphetamine abuse and/or dependence
Tranquilizer abuse and/or dependence
Hallucinogen abuse and/or dependence
Any substance-related disorder
Psychotic disorder
Schizophrenia
Any comorbid psychiatric disorder
* Numbers do not total 57 and percentages do not total 100% because subjects can have more than one comorbid diagnosis.5%). 4. Other common diagnoses included manic
episode (13 of 57.2
1.2
1
41
1.3
13.0.
The most prevalent categories of comorbid diagnoses for
women with posttraumatic stress disorder were mood
disorders.3%) wanted treatment for posttraumatic stress
disorder but did not receive it.2. One fourth of the women (15
of 57. 17. 21.3
24. 103.8 ⫾ 1.
the most prevalent was major depressive episode (24 of
57. 14.0.8
9.0. including sociodemographic.5
5.4
1.
drug dependence or abuse.0. 19.3
0. Although sociodemographic characteristics were not significantly different for
women with and those without posttraumatic stress disorder. NO. 29. nicotine dependence (10 of 57.
and social phobia (10 of 57. Of the 50 women who did not receive
posttraumatic stress disorder treatment in the previous
year.4
4.2
22. 81.3.9
0.Table 2. 22. By
using logistic regression. We found no
significant differences between the 2 groups in level of
impairment in the year before the interview. 11.9
0.8.8
22. 9.

Despite Medicaid coverage. Strong deterrents
to mental health service use include hearing bad things
about the care provided at a facility and fearing the
stigma associated with mental health treatment. miscarriages. difficulty with reduction of tobacco or other
substance use.
Only 12. housing problems involving relocation.15
Posttraumatic stress disorder may exert similar effects.14.9. posttraumatic stress disorder may not be identified in prenatal care settings. hyperemesis. Although the use of
alcohol may temporarily alleviate anxiety.7%. its negative effect
on fetal health is well documented.16 In a recent study. and interpersonal violence. some women with posttraumatic
stress disorder received treatment.
although no known research has documented this relationship in pregnant women. with a prevalence of 7. and erase memories of trauma. Women with posttraumatic stress disorder also
may have limited understanding of the value of mental
health treatment.12 Another factor that could influence generalizability is sampling from only urban and rural sites in a single
state. Greater awareness of symptoms related to this disorder. Breslau et al6 found that posttraumatic
stress disorder significantly increased the probability of
alcohol abuse and dependence.4 –7 Despite comparable rates in other studies. and long waiting times for appointments. women with posttraumatic stress disorder had more complications of
pregnancy. Optimal outcomes for women with
Cook et al
Posttraumatic Stress Disorder in Pregnancy
715
. Some research reports higher rates of
posttraumatic stress disorder in low-income populations. health providers in both prenatal
and primary care settings may miss the diagnosis of the
disorder.1% reported earlier by Ayers et
al.DISCUSSION
In this study of economically disadvantaged pregnant
women. An informed approach to helping women with these problems is likely to
increase compliance with prenatal care visit schedules
and health-promoting behavior. have known
negative consequences for both pregnant women and
their newborns.11 The lifetime prevalence of posttraumatic stress disorder (13. avoidance of
reminders of the trauma may hinder their seeking
needed health care services. barriers to their access
may be prohibitive. including maternal vulnerability to hypertension and increased susceptibility to infection. such as fear of pelvic
exams.
however. 4. Among
women who have been sexually abused.19 More likely. mental health services
are often limited in rural and inner city areas in this
country. particularly because the biological and psychological symptoms of this disorder may directly or indirectly affect
birth outcomes. Yehuda17
posits that traumatized persons with posttraumatic stress
disorder are more likely to visit their primary care physicians than mental health professionals for treatment of
symptoms. including intrusive medical
procedures in prenatal care.
poor nutrition. Prenatal assessments should detect those who need more extensive
evaluation of posttraumatic stress disorder and provide
treatment for the disorder. In this study. When services do exist. promote
sleep.6%) also corresponds to that found in the
general population of pregnant and nonpregnant women. and preterm contractions than their
counterparts without posttraumatic stress disorder. Despite these limitations. our
findings may not be generalizable to pregnant women
from higher socioeconomic levels or to women who are
not black or white. will enhance more effective
responses by health professionals.18 Another consideration is the often painful re-experiencing
of trauma that can be inherent in the treatment of this
disorder. Many of these behaviors. 103. a disincentive cited by the New Freedom Commission on Mental Health.
Several factors are involved in the low treatment rates
among pregnant women with posttraumatic stress disorder.13 Neuroendocrine
changes associated with chronic stress influence maternal–fetal health. APRIL 2004
setting itself that offers an ideal opportunity to identify
pregnant women with posttraumatic stress disorder and
make referrals for mental health treatment. Yet it is the prenatal care
VOL. a large proportion of women
reported they did not want treatment. posttraumatic stress disorder was the third most
common psychiatric disorder. and thus treatment referrals are not even made. such as lack of transportation. In this study. Seng
et al16 suggest that women with abuse-related posttraumatic stress disorder may not seek mental health treatment but might be open to other forms of help. inadequate child care.3% (7 of 57) of the women with posttraumatic
stress disorder received treatment for this disorder. including more ectopic pregnancies. posttraumatic stress disorder is common enough to be a clinical concern.
With the substantial overlap between symptoms of
posttraumatic stress disorder and those of depression
and anxiety disorders.
closely paralleling the 8. However. and anxiety that seems disproportionate
to presenting circumstances. Another
factor may involve women’s perceptions of their need
for services.17
The underlying mechanisms of how this disorder affects
these outcomes are unknown. NO. research links
high-risk behaviors to persons with posttraumatic stress
disorder.
The importance of adequate screening and treatment
of posttraumatic stress disorder during pregnancy is
strongly supported in the literature. but it was for another
psychiatric disorder. such as smoking.